Claimant Name   Submission Date   Client Information Company   Address   Adjuster   Phone    City   State   ZipCode     Email Confirm Email             Requested Services (Please check all that apply)   MEV - Medicare Eligibility Verification (w/Social Security Admin to evaluate the necessity for a Medicare Set-Aside Analysis)   MSA - Medicare Set-Aside Analysis (includes Medicare lein research and a Future Medical Cost Projection covering all expenses related to the injury/illness covered under this claim) FMCP Only - Future Medical Cost Projection (for Settlement Valuation - includes Medicare & non-Medicare covered expenses) EXPEDITED MSA SERVICE (Completed in 5 business days)      Court or Mediation Date Additional Services Available (Please check any additional services requested)      Drug Utilization Review (DUR)     Drug Utilization Peer Review   Medical Records & Payment History (Required) Once this Referral Information is submitted, a confirmation email will be sent to the email entered above.  This email will direct you to fax a complete payout history since the date of injury, showing provider names, dates of service, amounts paid, and insurance company payment codes.  If available, please provide detailed pharmacy payout history as well.  The email will provide the fax number and the Referral Submission Number to include on your fax cover sheet.           Claim Information Claimant's Name   Date of Birth   Claim Number(s)   State of Jurisdiction   Date(s) of Injury     SSD/SSDI and Medicare Information (where Available - Please leave blank if unknown) SSD Status Eligible   Applied   Pending   Denied Date    Medicare Status No    Yes     Medicare# Date  Claimant Information Address Employer (at time of injury) Apt/Unit# Employer's Address City Suite/Floor State City   ZipCode State Phone  ZipCode   Attorney / PBM Information / Structured Settlement Broker Utilize Rated Age Yes  No   Applicant's Counsel Defense Counsel SS Broker Firm Firm Firm Email   Email   Email   Address Address Address City City City State State State ZipCode ZipCode ZipCode Phone Phone Phone   PBM Company Phone Contact Name   File and Settlement Information Which body part(s) and/or condition(s) are accepted in this claim?     Is any portion of the claim denied? No Yes, in whole Yes, in part   Details: Which body parts or diagnoses are NOT accepted in this claim?     Is any portion of the claim disputed? No Yes, excluded Yes, disputed   Details: If disputed or excluded, which body part(s) and/or condition(s) are at issue?     Are any of the body parts/conditions NOT accepted in this claim being settled or addressed under another claim? No Yes   Please indicate proposed settlement amount or range $   Has the claim settled as a whole? No  Yes          Date   Amount  $   Comments (Anything else we should know about this case?)      Security Verification           Please enter the text shown in the Image